Clinical Evaluatio

ANSWER

Clinical Evaluation Study Notes and Descriptions
Chief complaint (CC): throbbing headache.

History of Present Illness (HPI): The patient rates 4/10 for pain when she reports a throbbing headache for the past two hours. The patient can feel a pulse in the temple area; the discomfort is localised.

past medical history (PMH):

Scoliosis repaired with a Charleston brace.
Background information on a broken toe.
Asthma brought on by sports.
Denies known drug allergies (NKDA) or current meds.
Social and Personal History (PSH)

Denies use of illegal drugs or tobacco.
Once a month, I sip wine.
Over the past three months, visited the UK and Caribbean.
single, lives alone.
I had last eye exams two years ago.
Review of Systems: ROS

Denies fever, changes in eyesight, cold or nasal symptoms, and other systemic concerns.
Reports a pounding headache with temple pulsating sensation.
Targeted vs. All-Inclusive Test
first evaluation:

Given the first complaint—a pounding headache—a targeted assessment could seem enough to handle the acute issue. To find the reason of the headache, this kind of test would focus on the neurological and head/neck systems.
Decision for the Comprehensive Exam:

After looking over the situation, the following justifies a thorough exam:

Since the patient is new to the office, creating a baseline medical record is rather important.
The travel history to the UK and Caribbean emphasises the need of looking for any exposures or diseases (such as infections or travel-related ailments).
The thorough prior medical history (scoliosis, asthma) and family dynamics call for a larger awareness of the patient’s health setting.
Encouraging Evidence A thorough exam is especially helpful for new patients, according to Bickley et al. (2021), as it helps personalise treatment, form a relationship, and provide a basis for further tests.

Clinical Exam Method: Complete Exam Components

General: Look for indications of systemic disease or acute pain.
Palpate temporal arteries for soreness or anomalies (e.g., temporal arteritis).
Examining cranial nerves, reflexes, and general neurological performance helps one rule out disorders including migraines or intracranial hypertension.
Cardiovascular: Look for irregularities or bruits that could aggravate headaches.
Respiratory: Look for any indicators of asthma flare-up since it could indirectly aggravate symptoms.
Questions About Travel: Screen for environmental exposures or infectious illnesses.
Topics of Questions:

Trigger for a headache could be recent stress, eating patterns, or allergy exposure.
Sleep Patterns: Any alterations that might aggravate headaches?
Family History: Either vascular diseases or migraines.
Nutrition and Hydration: Could dietary inadequacy or dehydration have a part?
At last
Although the first presentation points to a localised problem (headache), for a new patient a thorough exam is more suitable to create a baseline and guarantee that any contributory factors—including recent travel, lifestyle, and medical history—are taken into consideration. This method guarantees whole, patient-centered treatment and conforms with clinical best standards.

Consultation
In 2021 Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., Soriano, R. P., & Bates, B. Bates’s manual on history collecting and physical examination. Wolters Kluwer.

 

 

 

 

 

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